A mother on the child-abuse registry and evidence that intellectually disabled teenager Matthew Tirado hadn’t been in school for months was not enough to propel the state’s child-protection agency to make contact with Matthew and determine whether he was safe, according to a report by the state child advocate on a series of stunning lapses leading up to Matthew’s death in February.

Instead, the Department of Children and Families, after failing to see the 17-year-old even once in a nine-month period, during which a caseworker ignored a supervisor’s request to seek a police child-safety check, withdrew from Matthew’s case and ended its involvement in January 2017, just a month before his death. The $800 million-a-year agency closed its file rather than seeking to remove Matthew and his sister, who had also been neglected, from Katiria Tirado’s custody, Child Advocate Sarah Eagan reported.

After Matthew’s death, the medical examiner found he was emaciated and malnourished, weighed a paltry 84 pounds, and had the scars, bruises and healed rib fractures associated with prolonged physical abuse. He also had bed sores.

Tirado gave birth to Matthew shortly after she turned 16, with a man who was 34 years older. She was able to keep Matthew out of sight for months before his death. Matthew was diagnosed with autism and didn’t talk.

Yet critical information about Matthew’s life and plight remained buried in a thicket of DCF records, and the third and last DCF social worker to pick up the case was unaware of fundamental information that would have ratcheted up the danger level. This included the depth of Matthew’s helplessness, the fact that his sister had told another DCF social worker that Matthew was being hit at home, that the mother had a history of mental-health issues and had been neglected as a child herself, and that Matthew had not been in school for much of the last five years of his life, Eagan reported Tuesday.

DCF Commissioner Joette Katz, in an interview Tuesday in which she strongly defended the agency’s decisions in Matthew’s case, acknowledged that the internal record system, known as LINK, was obsolete and needs to be changed in order to give social workers better access to critical information.

Katz maintained that her agency should never have put the mother on its abuse registry. The incident, she said, involved the mother slapping her daughter in 2014. Katz said the appellate court has ruled that parents have the right to physically discipline their children up to a point.

As DCF closed its case on the family, Matthew — the subject of a half-dozen court hearings, a sheaf of abuse and neglect reports, and hours of discussion among school, court, and child-protection officials — was starving to death.

“Pictures obtained from Ms. Tirado’s cellphone confirmed that she had locked and shuttered her refrigerator and kitchen cabinets, restricting Matthew’s access to food,” Eagan wrote in a report released Tuesday afternoon.

“Text messages obtained by police investigators allegedly reflected Ms. Tirado’s knowledge that her son was starving and the criminal warrant alleged that Ms. Tirado “intentionally prevented [Matthew’s] access to food,” with Ms. Tirado reporting to a relative that Matthew was forced to seek food “from the garbage ...”

Katz stressed that DCF had no knowledge of the mother’s actions before Matthew’s death, and that the department was never presented with evidence that the boy was being subjected to serious physical harm.

“Nobody had any clue — I don’t care what anyone says — we did not know this child was being physically abused or starved to death,” Katz said. She added that family members and other adults who attended a party two days before Matthew’s death had seen the teen-ager, and that no one conveyed any suspicions of abuse to the department or anyone else.

Katz said her agency has no authority under state law to interview a child or enter a child’s home without parental permission — unless there is evidence that serious harm or sexual abuse was being inflicted on the child.

She said DCF has been pushing the legislature for 20 years to expand the department’s authority, to no avail.

Eagan said she strongly agrees the department should have more latitude to take action on behalf of children’s safety.

Eagan’s case study paints a portrait of public-agency inertia and disconnection, of a youth who wasn’t out of mind, but somehow remained out of sight, of a case that, despite mounting evidence, was never treated as an emergency — until the moment the mother called 911 and reported that her son had collapsed, was vomiting, and may be dying. Matthew was pronounced dead within two hours of reaching the hospital.

Each misstep led officials further away from a boy who couldn’t communicate and desperately needed the help of a safety net for which the public pays hundreds of millions of dollars a year to keep taut and springy — but in this case had evaporated, according to Eagan’s report.

The bottom line, Eagan told The Courant, is that the five neglect reports that DCF received from Hartford Public Schools in an 18-month period should have triggered a far more decisive response from the child-protection agency.

Katz also issued a written statement Tuesday reaffirming that DCF lacked the authority to compel Tirado to cooperate.

“Nothing diminishes the heartbreaking nature of what happened to Matthew; the level of abuse inflicted by the mother and intentional denial of food are egregious and incomprehensible,” Katz wrote.

“In this particular instance, the mother repeatedly denied child welfare, school, and law enforcement officials, among others, access to Matthew,” Katz asserted. “Lacking the authority to force the mother to cooperate and allow access to Matthew, none of these entities had evidence of the abuse that she inflicted on him. With that said, despite the limitations on what actions the department can take in light of parental resistance, the department has taken steps to improve the work of our agency.”

In the interview, Katz added, “There are a lot of systemic issues; it’s not just DCF … The legislature has tied our hands.”

Leslie Torres-Rodriguez, the superintendent of Hartford Public Schools, said in a statement that Matthew’s death “is a tragedy for all of us in the Hartford community.”

She said the school district “has been working closely with the Office of the Child Advocate and other agencies during the past year to revamp systems and protocols intended to protect students” and will “continue to address the critical need to identify shortcomings in the safety net for our children, especially our children with disabilities.”

Torres-Rodriguez said the child advocate’s report “identifies failings in our culture to serve children, and within the district’s policies, procedures and practices regarding chronic absenteeism … and proper collaboration with external agencies. With the support of the OCA and Hartford Public Schools’ Independent Monitor, the district is currently developing a ‘Whole Student Framework’ with the objective of changing staff culture on reporting suspected child abuse and neglect, providing optimal support for student needs, and creating opportunities for Social and Emotional Learning.”

In Matthew’s case, mistakes were made all along the way — by a school system that was concerned about Matthew but didn’t go far enough, by Matthew’s court-appointed lawyer, and by a system that didn’t demand that DCF produce Matthew and his sister and demonstrate they were safe, the report found. The mother never showed up for any of the critical juvenile-court hearings that led up to DCF closing its case.

Signs of danger were missed, Eagan wrote.

In November 2016, Hartford public schools “failed to contact DCF when Ms. Tirado withdrew Matthew’s sister from school for the purpose of home-schooling, despite the district having filed multiple child-protection reports between 2014 and May 2016 regarding both children.”

And there was this:

“Several supervisory directives to the DCF caseworker were not followed between July and December 2016, including to … confirm the family’s whereabouts through their landlord, follow-up with the school system, or request a police well-child safety check.”

Katz acknowledged that the social worker should have listened to the supervisor and requested the assistance of police. She also said the method the agency uses to assess risk was not properly carried out in this case, though she insisted that had it been done correctly, it would not have changed the department’s decisions.

And this:

“In December 2016 ... after nine months of not being allowed to see Matthew or verify his whereabouts, DCF submitted a written recommendation to the juvenile court requesting that the court terminate the case and end protective supervision early.”

Eagan reported that the DCF paperwork “did not spell out what efforts had been ... made to find the children and ensure their safety.”

The state’s principal child-protection department and Matthew’s court-appointed lawyer never sought orders from a judge that would have: kept the case open until Matthew and her sister were found and deemed safe; permitted “visitation of Matthew’s sister in school”; or sought “commitment of either child to state custody — despite grounds for such orders,” Eagan reported.

DCF asked to close its case without asserting whether taking that action was in the best interest of Matthew and his sister — as is required by law, Eagan wrote.

Katz said the attorney general’s office, which represents DCF, Matthew’s court-appointed lawyer, and the juvenile-couret judge agreed the case should be closed.

“If you can’t legally do anything more, what is the value of keeping the case open,” Katz said.

The child advocate’s report notes that the hearing to close the DCF case lasted 42 seconds.

Most of the agencies that touched Matthew’s case responded to the child advocate office’s request for commentary and input.

Hartford Public Schools “acknowledged ‘serious failings’ in the district’s practices regarding chronic absenteeism, as well as follow-up, communication, collaboration and response to parental notice of intent to home-school or withdraw children from the district.”

The school system “has already begun work implementing new protocols to ensure it does its part to fill the gaps in the safety net as swiftly and securely as possible,” Eagan wrote.

The office of the Chief Public Defender said it has updated its performance guidelines for assigned counsel for children and acknowledged the need for more training on issues “relating to the care and representation of children with all types of disabilities,” Eagan wrote.

The Judicial Branch said it was willing to try to tackle the problem “created by the refusal to appear or cooperate by a custodial parent suspected of abusing or neglecting a child subject to a court’s jurisdiction.”

DCF did not provide a written response to the report. However, agency spokesman Gary Kleeblatt said DCF cooperated with the child advocate’s office during the preparation of the report and indicated that a thorough internal review was conducted and improvements put in place.

Tirado, jailed with bail set at $200,000, is due back in court on Dec. 19.